1 Moroccan Experience in implementing methadone maintenance program AU MAROC Docteur Fatima ASOUAB et Dr Soumaya Rachidi Mental Health & drug Abuse program MINISTRY of HEALTH Kingdom of Morocco

 : 6194 case notifed AIDS: 4057  85 % heterosexual transmission  HIV Prevalence : 0.1 %  Estimated number PLHIV :  80% of PLHIV don’t know their status HIV Prevalence (SS 2010) Estimation of PLWHIV (2011): % of the case HIV/aids cases Pregnant women 0,17 % TB 0,83, % STI Patients 0,3 % Prisoners 0,8 % FSW 2,68 % IDUs 13,9 % MSM 3,16%

MoT Exercise 67% of the new infections in MARPs Networks (FSW, MSM, IDUs) ¼ of new infections in hetrosexual at low risk (due to the bridging populations)

 Drug Use  Rising drug use and substance abuse (2000s)  Weakness of the knowledge on HIV prevention by IDUs.  Low prevalence of HIV among IDUs (4%), but rising prevalence in the North (ex: 38% among IDUs in a North city)  Lack of HIV/AIDS services targeting IDUs  Harm Reduction  National strategic plan ( )  First NSP: 2008 (Tangier), 2010 (Tetouan, Nador) / North  Pilot Methadone Maintenance Treatment (MMT): June 2010  Evaluation process

Prestations des intervenants communautaires ( ONG)  Harm reduction program launched in 2007 in Tangier, Nador and Tétouan  Comprehensive program  IDU centers, NSP, Outreach work  methadone substitution program  Self Support  Peer education  Advocacy for DU human rights

 Pilot phase in 3 centres (Tangier, Rabat, Casablanca). Target: 100 patients  Targeting injecting users  DOT during pilot phase  Inclusion criteria  prioritization  Close to the MMT centre  Injectors  HIV positive  Women

 Facilitate the reduction of Heroine consumption  Facilitate the treatment of the somatic diseases  Facilitate the treatment of the psychiatric disorders comorbidity 7

 Viral contamination of HIV and Hepatitis prevention  Overdoses prevention  Improvement of the physical health  Improvement of Quality of life  Strengthening families relations  Facilitate the reinsertion in the work field - Insurance the women, an access to the program with equity and parity 8

Méthadone :  Better efficiency anti " craving "  Moderate price local Manufacturing  rarely injected Syrup  Syrup easy supervision  less good safety(security) of use) 9

 Necessary in the preliminary phase  Period of strong media sensitivity  Strengthening of teams capacity.  Need of including a large number of persons in treatment.  Temporary measure.  Avoid resale, sharing and criminal practice.  Risk of death in the community.  To insure sustainability of the program. 10

 Initial posology:  Men(People) (70 kg) = 20 mg (30 mg in the maximum / 1e 24 h) Women (55 kg) = 15 mg (25 mg in the maximum / 1th 24 h) Increase of posology:  mg / day if need Without exceeding 60 mg first week Always in 2 grips a day, the first 5 days (not equal) in The morning = total of the day before(wakefulness) + 5 in 10 mg in the evening 11

 Necessities to appreciate eligibility before the 1th Useful Day then if unpredictable rhythm (= 4 times / year) Never of negative consequences for patient Useful as:  Element of " fiabilisation " of declarative Marker of the evolution 12

 Keeping back (Number of pers. in MMT after one year)  Observance (Number of days of TTT / Nb days total %)  Reasons of relaps and for restarting the TTT.  Consumption of the injecting drugs  incidence HIV, VHC  Number of patients on ARV TTT.  Evolution of the Practices at risks.  Improvement Physical and psychiatric health.  Incidence of the deaths (and factors).  Incidence of the judicial events.  Social inclusion (housing, activity). 13

 After 1 year an external evaluation was conducted by the UNAIDS and UNODC support

 90 patients included since June 2010  82 still in retention (91%)  Drop out:  2 voluntary break (successful)  1 expelled  4 drop out during induction  1 dead (not associated to drug use)  Real baseline: 85  96% retention

 Gendered based: 10 (12%)  Mean age: 38 [21;61]  Injectors (56%) AND non-injectors (44%)  Duration of heroin use:  Mean: 16 years  Min:1 year  Max: 30 years  Middle to high social and economic conditions (family sustain, job, housing)

 Mean induction dosage: 33 mg [5 mg; 40 mg]  Mean induction phase: 5.8 days [2 days; 10 days]  Mean dosage at end of induction phase: 61 mg [25 mg; 80 mg]  Mean dosage at M12 (41 patients): 75 mg [20 mg; 130 mg]  Tangier: weekly or bi-weekly delivery for 44% patients

 Pilot phase: good results  Patients satisfaction: good (except DOT constraints)  No fatal incident  No diversion  Moroccan professionals get used with methadone protocol and practices  High level commitment  On behalf on those results: extension to prison setting